Gustaf Lernfelt

We have started with midwife-examinations for early discharge (6-12h from birth), followed by a physician eaxmination within 2 days. For infants staying at the maternity ward they will be examined once by a physcian before discharge, unless there are indications for more exams (murmurs, tachypnea, hypotonus etc.). This would be at 12-36 hours of age. Indications for staying in the maternity ward could be first born child, risk of infection, maternal health or other, but many choose early discharge with their second child. The midwives will do a basic exam but not listen to the hearth though, only do a pre-post-ductal saturation check, and they are not trained in finding more subtle finds associated with disease. I believe that for most babies it will be alright, but for some babies this could mean severe consecuenses, although they might be too few for it to be statistically significant upon review. On the other end of the spectrum I spoke with a couple of collegeues visiting from a country in south east Europe where every infant stayed for at least 5 days, and 7 days if there was a c-section. All the babies were examined once daily, and the well baby check shifts could be pretty hard in the weekends. Right now were are aiming at combining the maternity ward with our NICU at our smaller rural hospital, to be able to offer CPAP-care skin to skin and aiming at zero separation between mother and child. We have implemented this with some success at our post-op after c-sections and thereby been able to keep some newborns with TTN out of our intensive care unit.

Normalizing albumin could be aiming too high, but isn’t there a limit somewhere where you get a little uncomfortable as a doctor even though there isn’t much of an edema? I don't know where this threshold should be, how the evidence looks, or how low albumin could be accepted in relation to other functions besides oncotic pressure in a neonate, and would need to look that up. Does anyone have any thoughts on this? UpToDate recommends maintaining levels above 2 to 2.5 g/dL in this situation (article: Management of chronic pleural effusions in the neonate). As for AB-prophylaxis our immunodeficiency Professor recommended the use of trimethoprim / sulfamethoxazole in this specific case. UpToDate does not recommend routine use, but trim/sulfa in cases of severe lymphopenia (e.g. CD4 <200 c/mikroL). We have comparably few problems with antibiotic resistance in Sweden, this could possibly be insufficient in other countries. The UpToDate-article mentioned above offers a quite comprehensive review of management of chylothorax from a team at University of Alabama at Birmingham, and was last updated Oct 18 2024. I found it quite helpful! 😊 Thank you for starting this subject BTW!

We recently had a case born with hydrops secondary to chylothorax where we replaced 2/3 of losses with 50 percent plasma, 50 percent Ringer’s. Careful increase of feeding with Monogen, evaluating possible increase in fluid losses. Albumin intermittently.

Those posters were really great. I’ll add a couple of them here.

I was on Bluesky 🦋 and saw @AllThingsNeonatal share this study validating CGM-use in preterms 29-31 weeks, with an acceptable accuracy. https://www.jpeds.com/article/S0022-3476(24)00519-5/abstract For our hyperinsulinism infants, sometimes requiring glucose infusion, diazoxide and extensive carbohydrate enriched feeds, this is a very appealing approach.

In this particular case we were handling a suspected capillary leak syndrome, so I did some reading up on different treatments. Steroids was one treatment we considered. I ended up with an article form Iowa being most usefull: https://pubmed.ncbi.nlm.nih.gov/39123307/ It discussed possible treatment strategies (theophylline, IVIG, hydrocortisone) and provided a good supplemental with dosing suggestions. I also found an article on Haemodynamic effects of prophylactic post-operative hydrocortisone following cardiopulmonary bypass in neonates undergoing cardiac surgery: https://pubmed.ncbi.nlm.nih.gov/36950894/ But it was a retrospective, small sample size, with various other treatment regimes within the groups, so it didn't give that much. Except contributing to a possible dosing regime discussion. Another article proposed to give 3% NaCl boluses follwed by furosemide to treat a possible capillary leak. Due to it's fairly simple approach without too serious side effects it seemed like an attractive solution to the problem. But we never needed to try it out. https://pubmed.ncbi.nlm.nih.gov/38429824/ And since this was an overall edematous infant I also stumbled upon an article called: Neonatal fluid overload: ignorance is no longer bliss. Which covered everything we had tried (except for dialysis), it was a fairly good read. https://pubmed.ncbi.nlm.nih.gov/35348902/

Maybe @Pontus Johansson has something to add to this subject. He’s currently the chair of the pediatric section of the Swedish national resuscitation council.

There are guidelines published, here is one from France: https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2022.1075184/full Would love to hear more. Propofol is very commonly used in the PICU, but less so with our neonates. What would be the main reason to use it or not?

Don’t miss out on Neena Modi and Josef Neus recent commentary on the subject 🙂 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2824556?guestAccessKey=d560b308-01e0-4d52-b7d3-ca56cfe6a51d&utm_source=twitter&utm_medium=social_jamapeds&utm_term=14866058877&utm_campaign=article_alert&linkId=617958502

I was rather surprised of the results presented in this paper form Japan the other day: https://www.nature.com/articles/s41372-024-02093-0 While there is a small group and it has only been a two year follow up, the results are also showing better outcomes than expected for the group.

Dear Pototo, What work up have you done, and how did the case present itself?

Hi, While working the past couple of weeks, there has been some discussion on the possible membrane stabilizing effects of hydrocortisone. Is this something you would consider in your practice, in which cases, and what dose would you use? Whats is the evidence and rationale behind it? Best, Gustaf

I would tag in @Roland in this topic aswell. As an ANNP and an ultrasound guided vascular access-expert, he will be able to provide you with all the information you need. https://99nicu.org/meetup/speakers/roland-van-rens/

Could you please evolve, what would be the reason to supplement vitamin-K in patients taking antibiotics? Every neonate gets an intramuscular or intravenous (if i.m. is inappropriate) vitamin-K injection at birth. Full dose 1 mg if the weight is over 1500g, otherwise 0,5 mg. It should be sufficient, or is it something we would need to consider in regards to the infection? We give Numeta as parenteral nutrition, and add Vitalipid infant for fat soluble vitamines, it contains 0,02 mg/ml phytomenadione. Most preemies are introduced to enteral nutrition very early on, and with fortification when oral intake exceeds 70 ml/Kg/day. For longer treatment durations our guidelines recommends controlling for PK once a week if there is signs of liver failure, or if parenteral nutrition longer than 4 weeks (along with many other tests like transaminases, bili+konj bilim, albumin, magnesium, cobolamin, tokoferol etc. ).

I spoke to an american ANP at our 99nicu-Meetup who said that introducing the Kaiser score ( https://neonatalsepsiscalculator.kaiserpermanente.org/ )had really limited the antibiotic use in their unit. If I remember it correctly they had automated it into their digital journal system (Epic?). I'm not sure why we don't use it, is it implemented anywhere in Europe? But as CRP seems to be insufficient, even though we use it in combination with IL-6/Procalcitonin, it might be a good complement. Are there any disadvantages with Kaiser? The talk by Rene Kornelisse at the 99nicu meetup gave some food for thought on the subject of antibiotic use, let's see if we can publish it on the 99nicu Youtube-channel soon 🙂.

I'm not really sure what you are looking for here, but for ILFAD patients with intestinal failure we sometimes give oral vitamin-K 1 mg/kg/day. Otherwise vitamin K is supplemented in our fortification-formula (we use nutricias Nutriprem with Vitamine K 4mg/g), even though I saw a case report on HM-formula leading to vitamin-k deficiency ( https://pubmed.ncbi.nlm.nih.gov/37981048/ ).

Would you please like to tell us a little more about the project Prakash? I’m sure that people who would be interested would like to know thw answer to the following questions: Who are you and what is your role in this? What is the purpose of the trip? Where in India would this take place? How long will the trip be? Which is the organisation behind the funding? What level of care (if any) are you expected to be able to provide as a caregiver, Elaborate please, and good luck with your journey.

ESPGHAN and EFCNI recently published a joint statement on the issue available here: https://onlinelibrary.wiley.com/doi/full/10.1002/jpn3.12204

Adding some links for context: Reckitt charged with $60 million verdict: https://www.reuters.com/legal/reckitt-unit-hit-with-60-million-verdict-enfamil-baby-formula-case-illinois-2024-03-14/ The legal turns: https://www.law.com/2024/03/14/mead-johnson-hit-with-60m-verdict-in-first-nec-trial-over-preterm-infant-formula/?slreturn=20240224133119 As I’ve understood it they are fined for not warning about the increased risk for NEC compared to breast milk. As for breast milk, there are a number of ways to set up programmes for donor breast milk, wouldn’t that be the most reasonable approach?

Could you please further specify which challenges you would like to discuss? IFALD development? Feeding tolerance and high stoma outputs? Adequate growth? Long term outcomes? Acute surgical complications?

I’m not sure that this is what you are asking for, but they started mixning Nutricias Nutriprem in heated breastmilk instead of cold milk at the unit where I work right now. With the intention of better solubility, but the experiences from the nurses preparing the food was rather the opposite. More lumps, which could be a problem in our most preterm. This was uncovered during a small outbreak of various intestinal problems including a case of milk curd syndrome, why I believe we have returned to mixing it cold again. It could just be a random coincidence, but I would be interested in hearing more about how you could improve the preparation. Is there any small appliance for the purpose of better mixing?

Thank you for your feedback. It's really great to hear about how it's been implemented and tried. I believe a challenge could be that you need som subcutaneous fat for it to work properly and that there is a small delay between blood-sugars and interstitium. Better for LGA-babies of diabetic mothers than our SGA hypoglycemias perhaps.

Hi, I am managing a child with persistent hypoglycemia. While balancing carbohydrates, feeding etc. there have been a bit to many blood samples for me to be comfortable with. I was reading Gomella (Gomella's Neonatology 8th edition, 2020 pp 588-589) and they mention CGM:s being approved for the use in newborns, although not routinely used in clinical practice. I would like to ask if any of your units have implemented continous glucose monitoring? Which are the indications, at what gestational ages and weights? Which are your experiences with CGM, positive or negative? Are there any limitations? Best, Gustaf

Hi, we could add Neocardiolab and @spartacus007 Mprove Academy. https://www.neocardiolab.com/pocus And https://m.youtube.com/@mprove-multiprofessionalne4091/videos

Thank you for sharing great articles, do you know of any similar updates on the use of plasma infusions?